Limewood Nursing and Residential Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated Requires Improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulation in relation to people’s safe care and treatment in the way infection outbreaks were managed.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety, based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

We found no evidence of debriefs or follow-up actions linked to ABC charts. ABC charts are used to record changes in a person’s behaviour, identify triggers, and document the actions taken in response. This meant that lessons were not always learned following incidents of distressed behaviour to be able to prevent further incidents. Themes and trends were not identified through the monitoring of incidents to support staff to care for people safely in a way that met their individual needs at times of distress. The lack of learning from incidents of distressed behaviour meant that people may be at risk of harm.

To address this, the provider recently introduced a “Resident of the Day” initiative and began regular audits of ABC charts. These measures were intended to strengthen oversight and ensure behavioural incidents were monitored and managed effectively.

Staff listened to concerns about safety and investigated and reported safety events.

Relatives knew how to raise concerns or make a complaint. Relatives told us they were aware of the complaint’s procedure. Staff told us they supported people to understand how to raise concerns.

The provider worked with people and healthcare partners to maintain safe systems of care and ensure continuity, including during transitions between services. People experienced well-coordinated moves, with risk assessments reviewed before and after transitions.

Information was shared promptly with other providers, reducing delays and safeguarding wellbeing. Families were involved in planning, and staff explained processes clearly. One relative told us "Staff involve me in my relatives care so I know what’s going on.” Staff told us they worked closely with healthcare professionals to monitor health needs and respond to changes.

Visiting professionals confirmed the provider collaborated effectively when escalating concerns and making referrals. One professional said, “We aim for consensus and best interest decisions through partnership working.”

Clear risk assessments and protocols were in place for people with specific health conditions, and referrals were made appropriately when needs changed.

The provider worked with people and healthcare partners to maintain safe systems of care where safety was monitored and managed effectively. Staff focused on improving people’s lives while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Concerns were shared promptly and appropriately with relevant authorities, contributing to an open and responsive safeguarding culture. Staff had a clear understanding of their responsibilities to keep people safe. One staff member told us, “If I witnessed anything, I would raise it straight away with the manager. I know I could go to the CQC if I need to.”

The provider had effective systems in place to recognise, record and respond to information of concern. All staff had received up-to-date safeguarding training and were confident in how to raise and report incidents.

The provider worked with people to understand and manage risks holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans included clear guidance for managing emotional distress. People told us they felt safe; one person said, “I feel safe as people can’t get in without staff letting them in.”

People and relatives were included in discussions about care plans and risk assessments. One relative told us, “My family member and I are involved in their care plan.” Staff explained risks in simple language and encouraged people to share preferences.

The provider did not always detect and control potential risks in the care environment. They did not always make sure facilities, and technology supported the delivery of safe care.

There was uncertainty regarding whether water temperatures were checked as part of routine maintenance, as no evidence was available on the day of inspection. We did see evidence that care staff were checking water temperatures during tasks, however care providers are required to ensure weekly testing of water temperatures to ensure the safety of people using the service and to prevent scalding and reduce the risk of legionella. This lack of oversight and appropriate action to maintain safety meant that the provider was in breach of regulation in relation to safe care and treatment and ensuring the environment was safe for people. During feedback, the registered manager confirmed this would be included in their oversight of the service.

Environmental risk assessments were in place and reviewed regularly. Records showed that equipment such as hoists and wheelchairs was tested at appropriate intervals.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The registered manager determined staffing levels in line with people’s individual support needs. One relative told us, “When I visit, they always have enough staff”. Another relative told us, “I have seen positive training of staff.”

Staff received a comprehensive induction and regular training to ensure they had the skills and knowledge to support people effectively and safely this included face to face training and role play. Staff were recruited in a safe way. The provider had an effective recruitment procedure in place which included all appropriate checks.

The provider did not assess or manage the risk of infection effectively. There were failures to identify, control, and promptly share concerns with relevant agencies.

On the first day of inspection, we identified unclear and inconsistent communication regarding the presence of suspected scabies within the home. A staff member informed the inspector on the first day of the inspection that not everyone had been cleared of scabies and that a new case identified over the weekend had not been treated. Daily notes confirmed one individual with suspected scabies had not received treatment. Other staff were unsure if the home was clear of suspected scabies. The registered manager initially stated there were no active suspected cases; however, after speaking to staff evidence suggested otherwise. The registered manager was unable to confirm which residents or staff had received treatment and could not provide assurance that the home was free from active cases. Staff were not wearing appropriate Personal Protective Equipment (PPE) despite signage indicating a scabies risk. These issues created a risk of cross-infection to residents, staff, and visitors.

Due to the lack of coordination and effective management of the suspected outbreak, the inspection team made the decision to halt the inspection to prevent the risk of further spreading the scabies virus. The lack of coordinated risk management meant that the provider was in breach of regulation relating to safe, care and treatment and infection control.

Following these concerns, the registered manager acted promptly by creating an action plan on the same day. The provider confirmed the issue was due to miscommunication between staff and that there were no new cases of suspected scabies. The deputy manager completed a root cause analysis to identify how this occurred and implemented measures to prevent similar issues in the future.

The provider ensured medicines were managed safely and in line with people’s individual needs, capacities and preferences.

People were supported to make informed choices about their medicines. Where people lacked capacity, decisions were made in line with best interest principles and documented appropriately. One relative told us, “Any changes in my relative’s medication, my relative and I are included in the decision.” Another relative told us, “My relative has medication and they[staff] tell me what my relative is having.”

Medicines were stored securely, and records showed accurate administration. Staff followed the provider’s medicines policy, and regular audits monitored compliance and identified areas for improvement. These audits were used proactively to address minor discrepancies and reinforce good practice.

PRN (as required) protocols were in place, and we observed medicines being administered in a person-centred way. Staff documented the rationale for PRN use clearly, and records demonstrated compliance with policy.